Laura J. Damschroder

Preventing Hospital-Acquired Urinary Tract Infection in the United States: A National Study

BACKGROUND Although urinary tract infection (UTI) is the most common hospital-acquired infection in the United States, to our knowledge, no national data exist describing what hospitals in the United States are doing to prevent this patient safety problem. We conducted a national study to examine the current practices used by hospitals to prevent hospital-acquired UTI. METHODS We mailed written surveys to infection control coordinators at a national random sample of nonfederal US hospitals with an intensive care unit and >or=50 hospital beds (n=600) and to all Veterans Affairs (VA) hospitals (n=119). The survey asked about practices to prevent hospital-acquired UTI and other device-associated infections. RESULTS The response rate was 72%. Overall, 56% of hospitals did not have a system for monitoring which patients had urinary catheters placed, and 74% did not monitor catheter duration. Thirty percent of hospitals reported regularly using antimicrobial urinary catheters and portable bladder scanners; 14% used condom catheters, and 9% used catheter reminders. VA hospitals were more likely than non-VA hospitals to use portable bladder scanners (49% vs. 29%; P=.001), condom catheters (46% vs. 12%; P=.001), and suprapubic catheters (22% vs. 9%; P=.001); non-VA hospitals were more likely to use antimicrobial urinary catheters (30% vs. 14%; P=.001). CONCLUSIONS Despite the strong link between urinary catheters and subsequent UTI, we found no strategy that appeared to be widely used to prevent hospital-acquired UTI. The most commonly used practices--bladder ultrasound and antimicrobial catheters--were each used in fewer than one-third of hospitals, and urinary catheter reminders, which have proven benefits, were used in <10% of US hospitals.

Qualitative Content Analysis

Content analysis is a family of systematic, rule-guided techniques used to analyze the informational contents of textual data (Mayring, 2000). It is used frequently in nursing research, and is rapidly becoming more prominent in the medical and bioethics literature. There are several types of content analysis including quantitative and qualitative methods all sharing the central feature of systematically categorizing textual data in order to make sense of it (Miles & Huberman, 1994). They differ, however, in the ways they generate categories and apply them to the data, and how they analyze the resulting data. In this chapter, we describe a type of qualitative content analysis in which categories are largely derived from the data, applied to the data through close reading, and analyzed solely qualitatively. The generation and application of categories that we describe can also be used in studies that include quantitative analysis.

Preventing Ventilator-Associated Pneumonia in the United States: A Multicenter Mixed-Methods Study

OBJECTIVE To determine what practices are used by hospitals to prevent ventilator-associated pneumonia (VAP) and, through qualitative methods, to understand more fully why hospitals use certain practices and not others. DESIGN Mixed-methods, sequential explanatory study. METHODS We mailed a survey to the lead infection control professionals at 719 US hospitals (119 Department of Veterans Affairs [VA] hospitals and 600 non-VA hospitals), to determine what practices are used to prevent VAP. We then selected 14 hospitals for an in-depth qualitative investigation, to ascertain why certain infection control practices are used and others not, interviewing 86 staff members and visiting 6 hospitals. RESULTS The survey response rate was 72%; 83% of hospitals reported using semirecumbent positioning, and only 21% reported using subglottic secretion drainage. Multivariable analyses indicated collaborative initiatives were associated with the use of semirecumbent positioning but provided little guidance regarding the use of subglottic secretion drainage. Qualitative analysis, however, revealed 3 themes: (1) collaboratives strongly influence the use of semirecumbent positioning but have little effect on the use of subglottic secretion drainage; (2) nurses play a major role in the use of semirecumbent positioning, but they are only minimally involved with the use of subglottic secretion drainage; and (3) there is considerable debate about the evidence supporting subglottic secretion drainage, despite a meta-analysis of 5 randomized trials of subglottic secretion drainage that generally supported this preventive practice, compared with only 2 published randomized trials of semirecumbent positioning, one of which concluded that it was ineffective at preventing the development of VAP. CONCLUSION. Semirecumbent positioning is commonly used to prevent VAP, whereas subglottic secretion drainage is used far less often. We need to understand better how evidence related to prevention practices is identified, interpreted, and used to ensure that research findings are reliably translated into clinical practice.

How Active Resisters and Organizational Constipators Affect Health Care–Acquired Infection Prevention Efforts

BACKGROUND As of October 2008, hospitals in the United States no longer receive Medicare reimbursement for certain types of health care-associated infection (HAI), thereby heightening the need for effective prevention efforts. The mere existence of evidence-based practices, however, does not always result in the use of such practices because of the complexities inherent in translating evidence into practice. A qualitative study was conducted to determine the barriers to implementing evidence-based practices to prevent HAI, with a specific focus on the role played by hospital personnel. METHODS In-depth phone and in-person interviews were conducted between October 2006 and September 2007 with 86 participants (31 physicians) including chief executive officers, chiefs of staff, hospital epidemiologists, infection control professionals, intensive care unit directors, nurse managers, and frontline physicians and nurses, in 14 hospitals. FINDINGS Active resistance to evidence-based practice change was pervasive. Successful efforts to overcome active resisters included benchmarking infection rates, identifying effective champions, and participating in collaborative efforts. Organizational constipators-mid- to high-level executives who act as insidious barriers to change-also increased the difficulty in implementing change. Recognizing the presence of constipators is often the first step in addressing the problem but can be followed with including the organizational constipator early in group discussions to improve communication and obtain buy-in, working around the individual, and terminating the constipators employment. DISCUSSION Two types of personnel-active resistors and organizational constipators-impeded HAI prevention activities, and several approaches were used to overcome those barriers. Hospital administrators and patient safety leaders can use the findings to more successfully structure activities that prevent HAI in their hospitals.

Small-Changes Obesity Treatment Among Veterans: 12-Month Outcomes

BACKGROUND Weight-loss trials tend to recruit highly selective, non-representative samples. Effective weight-loss approaches are needed for real-world challenging populations. PURPOSE To test whether a small-changes intervention, delivered in groups or via telephone, promotes greater weight loss than standard obesity treatment in a predominantly male, high-risk Veteran population. Data were collected in 2010-2012 and analyzed in 2013. DESIGN A three-arm, 12-month randomized pragmatic effectiveness trial. SETTING/PARTICIPANTS Four-hundred eighty-one overweight/obese participants from two Midwestern Veterans Affairs (VA) Medical Centers were randomly assigned to one of three programs: the 12-month Aspiring to Lifelong Health (ASPIRE) weight-loss program delivered (1) individually over the phone (ASPIRE-Phone) or (2) in-person group sessions (ASPIRE-Group); compared to (3) VAs standard weight-loss program (MOVE!). INTERVENTION Twenty-eight sessions with a non-clinician coach via telephone or in-person groups using a small-changes obesity treatment approach compared to a 15-30-session standard VA program. MAIN OUTCOME MEASURES Twelve-month change in weight (kilograms). RESULTS Participants in all three arms lost significant (p<0.01) weight at 12 months. Participants in the ASPIRE-Group arm lost significantly more weight at 12 months than those in the other two treatment arms (-2.8 kg, 95% CI=-3.8, -1.9, in ASPIRE-Group vs -1.4 kg, 95% CI=-2.4, -0.5, in ASPIRE-Phone and -1.4 kg, 95% CI=-2.3, -0.4) in MOVE!(®). ASPIRE-Group resulted in greater improvements in all other anthropometric measures compared to MOVE! at 12 months (p<0.05) and for all (p<0.05) but waist circumference (p=0.23) compared to ASPIRE-Phone. CONCLUSIONS Group-based delivery of the ASPIRE weight management program is more effective than MOVE! and the phone-based version of ASPIRE at promoting sustained weight loss in a predominantly male population with multiple comorbidities. The incremental benefits of group-based ASPIRE over the current MOVE! program could yield significant population-level benefits if implemented on a large scale.

The validity of person tradeoff measurements: Randomized trial of computer elicitation versus face-to-face interview

Can person tradeoff (PTO) value judgments be elicited by a computer, or is a face-to-face interview needed? The authors randomly assigned 95 subjects to interview or computer methods for the PTO, a valuation measure that is often difficult for subjects. They measured relative values of foot numbness, leg paralysis, and quadriplegia (all 3 pairs) at 2 reference group sizes (10 or 100). Relative values did not differ between computer and interview. Overall, 21% of responses were equality responses, 13% were high extreme values, and 5% violated ordinal criteria. The groups did not differ in these measures. The authors also assessed consistency across reference group size (10 v. 100). Although relative values were significantly lower for 100 than for 10, mode did not influence the size of this effect. Subjects made, on average, equally consistent judgments for the 3 comparisons. A computerized PTO elicitation protocol produced results of similar quality to that of a face-to-face interview.

A randomized trial of a small changes approach for weight loss in veterans: design, rationale, and baseline characteristics of the ASPIRE-VA trial.

BACKGROUND Overweight/obesity rates among veterans are higher than the national average. While weight management treatment has been implemented in the Veterans Health Administration (VHA), program data shows low enrollment, participation, and weight loss. This paper presents the design, rationale and baseline characteristics of a multisite, multi-modality, randomized clinical trial assessing an innovative Small Changes (SC) approach on weight loss compared to the current weight management program in the VHA. METHOD Overweight/obese veterans were recruited from two VHA medical centers. Participants were randomized to either: 1) sc group, 2) SC phone, or 3) usual care. Participants in the SC arms met with health coaches weekly in months 1-3, bi-weekly in months 4-9, and monthly in months 10-12. Usual care participants met weekly for 12 weeks with limited options for follow-up care. The primary outcome is weight at 12 months. Secondary outcomes include physiological, behavioral, psychosocial outcomes along with participation and adherence. RESULTS Participants include 481 veterans who are middle-aged (M=55.45, SD=10.00), obese (BMI=36.45, SD=6.24), relatively sedentary (M=4721 steps per day; SD=3115), disabled (52%), men (85%) with a large minority of non-white race/ethnicity (43%) and high prevalence of physical co-morbidities (83%) (Charlson Co-morbidity Index M=1.27, SD=1.75) and mental health disorders (57%) at baseline. CONCLUSION The present study seeks to determine if an SC approach, delivered either via phone or in-person, will result in greater weight loss and program participation and adherence at 12 months compared to usual care.

Deliberative assessment of surrogate consent in dementia research

Research involving incapacitated persons with dementia entails complex scientific, legal, and ethical issues, making traditional surveys of layperson views on the ethics of such research challenging. We therefore assessed the impact of democratic deliberation (DD), involving balanced, detailed education and peer deliberation, on the views of those responsible for persons with dementia.

Effect of public deliberation on attitudes toward surrogate consent for dementia research

Objective: To assess the informed, deliberative views of the older general public toward a policy of allowing surrogate consent for Alzheimer disease (AD) research. Methods: A total of 503 persons aged 50+ recruited by random digit dialing were randomly assigned to 1 of 3 groups: deliberation, education, or control. The deliberation group attended an all-day education/peer deliberation session; the education group received written information only. Participants were surveyed at baseline, after deliberation session (or equivalent time), and 1 month after the session, regarding their attitudes toward a policy of allowing surrogate consent for research studies of varying risks and potential benefits (a lumbar puncture study, a drug randomized controlled trial, a vaccine randomized controlled trial, and an early phase gene transfer trial). Results: At baseline, a policy of surrogate consent for AD research was supported by 55%–91%, depending on the scenario. The education group had a transient increase in support for one research scenario after receiving the information materials. In the deliberation group, support for surrogate consent was higher after deliberation for all scenarios (67% to 97%), with much of the increase sustained 1 month after the deliberation session. No changes occurred in the control group. The studys limitations include self-selection of participants due to the demanding nature of attendance at the deliberation sessions. Conclusions: This sample of the older general public generally supported a policy of surrogate consent for AD research at baseline. Their support increased with democratic deliberation involving informed, in-depth exploration of the relevant scientific and ethical issues.

What's It Worth? Public Willingness to Pay to Avoid Mental Illnesses Compared With General Medical Illnesses

OBJECTIVE Allocation of resources for the treatment of mental illness is low relative to the burden imposed by these illnesses. The reason for this discrepancy has not been established. Few studies have directly and systematically compared public evaluations of the importance of treating mental illnesses and general medical illnesses. This study assessed public willingness to pay for treatments of mental health conditions and of general medical conditions to determine whether willingness to pay less for mental health treatments is due to the perception that mental health conditions are less burdensome. METHODS U.S. adults (N=710) in a nationally representative sample were provided with descriptions of two mental and three general medical illnesses. Respondents rated their willingness to pay to avoid each illness and then their perception of the burdensomeness of each illness. RESULTS Participants rated the two mental illnesses as relatively more burdensome than the general medical illnesses, but the amount they were willing to pay to avoid the mental illnesses was lower. Specifically, participants were willing to pay 40% less to avoid the mental illnesses compared with the general medical conditions, for a comparable benefit in terms of quality of life. CONCLUSIONS Even though respondents recognized that severe mental illnesses can dramatically lower quality of life, they were less willing to pay to avoid such illnesses than they were to pay to cure less burdensome general medical illnesses.